Phytochemical evaluation of roots of Plumbago zeylanica L. and assessment of its potential as a nephroprotective agent

Search for medicinal plants to treat kidney disorders is an important topic on phytotherapeutical research. Plumbago zeylanica L. is an important medicinal plant with hepatoprotective, anti-inflammatory, anti-diabetic, anti-cancer and anti-hyperlipidemic activities. In the present study, the protective effect of hydroalcoholic extract of P. zeylanica (HAPZ) in cisplatin induced nephrotoxicity was analyzed in Swiss albino mice. Treatment with higher dose (400 mg/kg) of HAPZ significantly reversed the adverse effect of cisplatin on kidney weight, serum urea and creatinine, indicating their renoprotective effect. The antioxidant effect of the drug is evident from its significant effect on Catalase, Glutathione peroxidase and lipid peroxidation activities.

Measurement of the Neutrino Mixing Angle θ_{23} in NOvA

This Letter reports new results on muon neutrino disappearance from NOvA, using a 14 kton detector equivalent exposure of 6.05×10^{20} protons on target from the NuMI beam at the Fermi National Accelerator Laboratory. The measurement probes the muon-tau symmetry hypothesis that requires maximal θ_{23} mixing (θ_{23}=π/4). Assuming the normal mass hierarchy, we find Δm_{32}^{2}=(2.67±0.11)×10^{-3}  eV^{2} and sin^{2}θ_{23} at the two statistically degenerate values 0.404_{-0.022}^{+0.030} and 0.624_{-0.030}^{+0.022}, both at the 68% confidence level. Our data disfavor the maximal mixing scenario with 2.6σ significance.

The BiPo-3 detector

The BiPo-3 detector is a low radioactive detector dedicated to measuring ultra-low natural contaminations of ²⁰⁸Tl and ²¹⁴Bi in thin materials, initially developed to measure the radiopurity of the double β decay source foils of the SuperNEMO experiment at the μBq/kg level. The BiPo-3 technique consists in installing the foil of interest between two thin ultra-radiopure scintillators coupled to low radioactive photomultipliers. The design and performances of the detector are presented. In this paper, the final results of the ²⁰⁸Tl and ²¹⁴Bi activity measurements of the first enriched ⁸²Se foils are reported for the first time, showing the capability of the detector to reach sensitivities in the range of some μBq/kg.

Abstract P3-17-06: LORIS trial of active monitoring for DCIS: How does the online pathology eligibility review process work?

Introduction

The LORIS Trial is a UK randomized clinical trial comparing active monitoring with surgery for low risk ductal carcinoma in situ (DCIS), defined as low or low-intermediate grade DCIS without comedo necrosis, as diagnosed on vacuum-assisted (wide bore) core needle samples. Because of the inconsistency of grading DCIS, we have underpinned this trial with a Central Histopathology Review (CHR) before randomisation. The process of the CHR for the first 22 months of a two year pilot study between July 2014 and May 2016 is reported here.

Patients and methods

Patients were eligible for CHR if they satisfied all of the eligibility criteria and had locally reported low or intermediate grade DCIS. Patients were identified at 28 pilot sites and were registered for potential trial entry following written informed consent before being subjected to CHR. CHR comprised online examination of digitally scanned histology slides of all material from all diagnostic biopsies and was performed by at least two of the three LORIS specialist breast pathologists. Histology slides were submitted using Royal Mail Safebox® to the University of Birmingham where they were digitally scanned and made available for review via the Leica digital image hub. The outcome of the review was reported in a separate secure online database by completion of a Central Pathology Review Form. Access to both online systems is password protected. Eligibility was confirmed if two pathologists agreed that there was low or low to intermediate grade DCIS and no comedo necrosis. A maximum of 7 calendar days from receipt of the diagnostic material was allowed for the central review process.

The digital images of the histology slides are stored by the Leica system for future reference.

Results

100 patients were registered and their slides reviewed. 55 of these were deemed eligible by CHR; of these 38 have been randomised. 45 patients were deemed ineligible, most commonly due to grade being in the upper half of the intermediate category and/or comedo necrosis. In addition, 9 patients were deemed not to have DCIS and 1 patient had invasive disease.

Grouping the grade categories as low and low to intermediate grade (low risk and eligible for randomisation) Vs intermediate to high and high cytonuclear grade (ineligible for randomisation) showed 91% agreement on grade category amongst the reviewing pathologists.

Results of the central review were made available to sites within 7 days for 97% of cases submitted. On average, central review was completed within 4 days. Average time between registration and randomisation was 3 weeks. The LORIS central review pathologists found online viewing and reporting of sections acceptable.

Conclusions

Central Histopathology Review using online viewing of digital slides provides timely and efficient pathology Quality Assurance in this clinical trial setting, with acceptable turnaround times and good agreement between reviewing specialist breast pathologists. This process will be continued in the main phase of the trial.

Citation Format: Thomas J, Hanby A, Pinder S, Pirrie S, Rea D, Gaunt C, Young J, Francis A. LORIS trial of active monitoring for DCIS: How does the online pathology eligibility review process work? [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-17-06.

Abstract OT1-03-01: The UK LORIS trial: Randomizing patients with low or low intermediate grade ductal carcinoma in situ (DCIS) to surgery or active monitoring

Background: The independent review of the UK National Health Service Breast Screening Programme reported (The Lancet, Volume 380, Issue 9855, Page 1778, 17 Nov 2012) on the benefits and harms of breast screening. It concluded that breast screening saves lives and acknowledged the existence of overtreatment. It encouraged randomized trials to elucidate the appropriate treatment of screen-detected DCIS to gain a better understanding of its natural history. The LORIS trial addresses the possible overtreatment of low and low/intermediate grade screen-detected (low risk) DCIS by randomizing patients to standard surgical treatment or active monitoring, each with long term follow up.

Trial Design: LORIS is a phase III, multicentre, 2 arm study, with a built in 2 year Feasibility Phase, in patients confirmed to have low risk DCIS defined by strict criteria and determined by central pathology review. Patients will be randomized between standard surgery and active monitoring with annual mammography. Patients will be followed up for a minimum of 10 years.

Eligibility Criteria:

1) Female, age ≥ 46 years

2) Screen-detected or incidental microcalcification (with no mass lesion clinically or on imaging)

3) Low risk DCIS on large volume vacuum-assisted biopsy, confirmed by central pathology review

4) Patient fit to undergo surgery

5) No previous breast cancer or ipsilateral DCIS diagnosis

6) Written informed consent

Specific Aims: The LORIS Trial aims to establish whether patients with newly diagnosed low risk DCIS can safely avoid surgery without detriment to their wellbeing (psychological and physical) and whether those patients that do require surgery can be identified by pathological and radiological means.

Primary endpoint: Ipsilateral invasive breast cancer free survival time

Secondary endpoints: Overall survival; mastectomy rate; time to mastectomy; time to surgery; patient reported outcomes; health resource utilisation and assessment of predictive biomarkers.

A digital image data repository and tissue bank will provide a prospective resource for both translational and imaging studies.

Statistical Methods: A total of 932 patients will be randomized to a non-inferiority design to test the null hypothesis that active monitoring of women diagnosed with low risk DCIS is not non-inferior in terms of ipsilateral invasive breast cancer free survival (iiBCFS) time compared to treatment with surgery. The iiBCFS time will be compared across the two arms on a per protocol and intent-to-treat basis, using a 1-sided (α=0.05) log-rank test for non-inferiority. The iiBCFS rate is assumed to be 97.5% in the surgery arm at 5 years, utilizing 80% power to exclude a difference of more than 2.5% in the active monitoring arm.

Present Accrual and Target Accrual: 32 UK centres are open for the Feasibility Phase of the trial which is nearing completion. The web-based central pathology review process is functioning efficiently, with a one week maximum turn around. Registrations and sites randomizing patients are on or above target. Randomizations are currently approximately 70% of target. A total of 60 centres will open in the main trial.

Contact Information: For further information, please email the LORIS Trial Office LORIS@trials.bham.ac.uk.

Citation Format: Francis A, Bartlett J, Billingham L, Bowden S, Brookes C, Dodwell D, Evans A, Fairbrother P, Fallowfield L, Gaunt C, Hanby A, Jenkins V, Matthews L, Pinder S, Pirrie S, Rea D, Reed M, Roberts T, Thomas J, Wallis M, Wilcox M, Young J. The UK LORIS trial: Randomizing patients with low or low intermediate grade ductal carcinoma in situ (DCIS) to surgery or active monitoring [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT1-03-01.

SaudiVeg ecoinformatics: Aims, current status and perspectives

During the last decade many electronic databases of vegetation plots were established in many countries around the world. These databases contain valuable phytosociological information assisting both governmental and NGO (Non-governmental organizations) agencies to formulate strategies and on-ground plans to manage and protect nature resources. This paper provides an account on aims, current status and perspectives of building of a vegetation database for the Central Region (Najd) of Saudi Arabia – the founding element of the Saudi Vegetation Database (SVD). The data stored by the database are sample plots (vegetation relevés) collected according to the field techniques of the Braun-Blanquet approach (lists of taxa accompanied by semi-quantitative cover assessment), and are accompanied by general vegetation characteristics such as vegetation layering and cover, information on life-form of the recorded species, geographical coordinates, altitude, soil typology, topography and many more. More than 2900 vegetation-plot records (relevés) have so far been collected in the Najd region; of these more than 2000 have already been stored using the Turboveg database platform. These field records cover many habitats such as depressions, wadis (dry river beds), agricultural lands, sand dunes, sabkhas, and ruderal habitats. The ecological information collected in the database is currently the largest set of vegetation data collated into a database in the Middle East. These data are of great importance for biodiversity studies in Saudi Arabia, since the region is recording a loss of biodiversity at a fast rate due to environmental problems such as global warming and land-use changes. We envisage that this database would catalyze further data collection on vegetation of the entire Arabian Peninsula, and shall serve as one of the most important datasets for classification and mapping of the vegetation of the Kingdom of Saudi Arabia.

Killing by Type VI secretion drives genetic phase separation and correlates with increased cooperation

By nature of their small size, dense growth and frequent need for extracellular metabolism, microbes face persistent public goods dilemmas. Genetic assortment is the only general solution stabilizing cooperation, but all known mechanisms structuring microbial populations depend on the availability of free space, an often unrealistic constraint. Here we describe a class of self-organization that operates within densely packed bacterial populations. Through mathematical modelling and experiments with Vibrio cholerae, we show how killing adjacent competitors via the Type VI secretion system (T6SS) precipitates phase separation via the 'Model A' universality class of order-disorder transition mediated by killing. We mathematically demonstrate that T6SS-mediated killing should favour the evolution of public goods cooperation, and empirically support this prediction using a phylogenetic comparative analysis. This work illustrates the twin role played by the T6SS, dealing death to local competitors while simultaneously creating conditions potentially favouring the evolution of cooperation with kin.

An overview of wetlands of Saudi Arabia: Values, threats, and perspectives

The wetlands of Saudi Arabia are located in a water-stressed region that is highly vulnerable to climate and other global changes. Sebkhas, mudflats, mangroves, and wadis are the dominant wetlands in the arid regions of North Africa and the Arabian Peninsula. These unique wetlands are recognized as a sanctuary for biodiversity and for their economic services generated from mineral extraction, agriculture, and grazing. Despite their ecological values and societal services, the long-term permanence of Saudi Arabia's wetlands faces strong challenges resulting from human activities associated with sustained population growth, habitat degradation, and coastal development. This paper consolidates a literature review of Saudi Arabia's wetlands from local to global importance, highlights their biodiversity, and identifies threats and evolution of these vulnerable ecosystems in the arid Arabian Peninsula by focusing on the status of key freshwater taxa (Odonata, freshwater fishes, amphibians, and waterbirds) and documenting changes affecting important wetlands.

A Community-Based Oral Health Intervention in Navajo Nation Head Start: Participation Factors and Contextual Challenges

Successful interventions require consistent participation by intended recipients. We utilized mixed methods to describe participation of 518 parent-child dyads enrolled in a randomized cluster trial of a 2-year oral health intervention for Head Start (HS) families across Navajo Nation delivered by native Community Oral Health Specialists (COHS). We quantitatively assessed factors that contributed to participation and qualitatively examined barriers and strategies. The intervention offered fluoride varnish (FV) and oral health promotion (OHP) activities for two cohorts (enrolled in 2011, N = 286, or 2012, N = 232) of children in the HS classrooms and OHP for parents outside the classroom. Child participation was good: FV: 79.7 (Cohort 1) and 85.3 % (Cohort 2) received at least 3 of 4 applications; OHP: 74.5 (Cohort 1) and 78.4 % (Cohort 2) attended at least 3 of 5 events. Parent participation was low: 10.5 (Cohort 1) and 29.8 % (Cohort 2) attended at least three of four events. Analysis of survey data found significant effects on parent participation from fewer people in the household, Cohort 2 membership, greater external-locus of control, and a greater perception that barriers existed to following recommended oral health behaviors. Qualitative analysis of reports from native field staff, COHS, community members, and the research team identified barriers (e.g., geographic expanse, constraints of a research trial) and suggested strategies to improve parent participation (e.g., improve communication between COHS and parents/community). Many challenges to participation exist when conducting interventions in rural areas with underserved populations. Working with community partners to inform the development and delivery of interventions is critical.

The platypus nest: burrow structure and nesting behaviour in captivity

The platypus nesting burrow, where females lay eggs and rear their young, has not been well studied. We have little knowledge of its structure and the process of construction. This study aimed to investigate nesting behaviour of breeding females and to describe the structure and features of the burrow. We used infrared cameras to record behaviour of captive breeding female platypuses during the nest-building period, over nine years. After the young had become independent, we excavated 11 nesting burrows and mapped their structural features. Nesting behaviour was observed 7–15 days after mating and was an indicator of gravidity. Females invested an average of 8 h 18 min over 3.5 nights, gathering and transporting wet nesting material to their burrows. The nests were composed mostly of native mat-rush leaves. Nesting burrows varied in length from 3.2 to 10.4 m. They contained narrow tunnels, ‘pugs’ of backfilled earth, dead ends, multiple entrances and a chamber at the end that contained the nest. Appropriate nesting sites and nesting materials must be provided to female platypuses for captive breeding programs to succeed.

Patency of paediatric endotracheal tubes for airway instrumentation

BACKGROUND

Airway exchange catheters (AEC) and fiberoptic bronchoscopes (FOB) for tracheal intubation are selected so that there is only a minimal gap between their outer and inner diameter of endotracheal tube (ETT) to minimize the risk of impingement during airway instrumentation. This study aimed to test the ease of passage of FOBs and AECs through paediatric ETT of different sizes and from different manufacturers when using current recommendations for dimensional equipment compatibility taken from text books and manufacturers information.

METHODS

Twelve different brands of cuffed and uncuffed ETT sized ID 2.5 to 5.0 mm were evaluated in an in vitro set-up. Ease of device passage as well as the locations of an impaired passage within the ETT were assessed. Redundant samples were used for same sized ETT and all measurements were triple-checked in randomized order.

RESULTS

In total, 51 paired samples of uncuffed as well as cuffed paediatric ETT were tested. There were substantial differences in the ease of ETT passage concordantly for FOBs and AECs among different manufacturers, but also among the product lines from the same manufacturer for a given ID size. Restriction to passage most frequently was found near the endotracheal tube tip or as a gradually increasing resistance along the ETT shaft.

CONCLUSIONS

Current recommendations for dimensional equipment compatibility AECs and FOBs with ETTs do not appear to be completely accurate for all ETT brands available. We recommend that specific equipment combinations always must be tested carefully together before attempting to use them in a patient.

Oxytocin improves synchronisation in leader-follower interaction

The neuropeptide oxytocin has been shown to affect social interaction. Meanwhile, the underlying mechanism remains highly debated. Using an interpersonal finger-tapping paradigm, we investigated whether oxytocin affects the ability to synchronise with and adapt to the behaviour of others. Dyads received either oxytocin or a non-active placebo, intranasally. We show that in conditions where one dyad-member was tapping to another unresponsive dyad-member – i.e. one was following another who was leading/self-pacing – dyads given oxytocin were more synchronised than dyads given placebo. However, there was no effect when following a regular metronome or when both tappers were mutually adapting to each other. Furthermore, relative to their self-paced tapping partners, oxytocin followers were less variable than placebo followers. Our data suggests that oxytocin improves synchronisation to an unresponsive partner’s behaviour through a reduction in tapping-variability. Hence, oxytocin may facilitate social interaction by enhancing sensorimotor predictions supporting interpersonal synchronisation. The study thus provides novel perspectives on how neurobiological processes relate to socio-psychological behaviour and contributes to the growing evidence that synchronisation and prediction are central to social cognition.

Development of quality standards of medicinal mistletoe - Helicanthes elastica (Desr.) Danser employing Pharmacopoeial procedures

Helicanthes elastica (Desr.) Danser (Loranthaceae), commonly known as Indian mango mistletoe, is a parasitic shrub found widely growing on mango trees in southern India. Development of monographic quality standards is need of the hour for Pharmacopoeial/extra-Pharmacopoeial and folk medicinal plants. Systematic pharmacognostical evaluation of leaves of H. elastica has been carried out employing Pharmacopoeial procedures of testing herbal drugs. Macro–microscopic features of H. elastica leaf were recorded. Ethanolic extract was tested positive for alkaloids, steroids, carbohydrates, tannins, saponins and phenols. HPTLC fingerprint profile was developed for the identification of extracts using reference standard β-sitosterol glucoside. Results of the present investigation would serve as a source of pharmacognostical information and a document to control the quality of H. elastica (Desr.) Danser.

Interpretive analysis of 85 systematic reviews suggests that narrative syntheses and meta-analyses are incommensurate in argumentation

Using Toulmin's argumentation theory, we analysed the texts of systematic reviews in the area of workplace health promotion to explore differences in the modes of reasoning embedded in reports of narrative synthesis as compared with reports of meta‐analysis. We used framework synthesis, grounded theory and cross‐case analysis methods to analyse 85 systematic reviews addressing intervention effectiveness in workplace health promotion. Two core categories, or ‘modes of reasoning’, emerged to frame the contrast between narrative synthesis and meta‐analysis: practical–configurational reasoning in narrative synthesis (‘what is going on here? What picture emerges?’) and inferential–predictive reasoning in meta‐analysis (‘does it work, and how well? Will it work again?’). Modes of reasoning examined quality and consistency of the included evidence differently. Meta‐analyses clearly distinguished between warrant and claim, whereas narrative syntheses often presented joint warrant–claims. Narrative syntheses and meta‐analyses represent different modes of reasoning. Systematic reviewers are likely to be addressing research questions in different ways with each method. It is important to consider narrative synthesis in its own right as a method and to develop specific quality criteria and understandings of how it is carried out, not merely as a complement to, or second‐best option for, meta‐analysis. © 2016 The Authors. Research Synthesis Methods published by John Wiley & Sons Ltd.

Alcohol advertising and public health: systems perspectives versus narrow perspectives

BACKGROUND

Alcohol consumption is influenced by a complex causal system of interconnected psychological, behavioural, social, economic, legal and environmental factors. These factors are shaped by governments (eg, licensing laws and taxation), by consumers (eg, patterns of alcohol consumption drive demand) and by alcohol industry practices, such as advertising. The marketing and advertising of alcoholic products contributes to an 'alcogenic environment' and is a modifiable influence on alcohol consumption and harm. The public health perspective is that there is sufficient evidence that alcohol advertising influences consumption. The alcohol industry disputes this, asserting that advertising only aims to help consumers choose between brands.

METHODS

We review the evidence from recent systematic reviews, including their theoretical and methodological assumptions, to help understand what conclusions can be drawn about the relationships between alcohol advertising, advertising restrictions and alcohol consumption.

CONCLUSIONS

A wide evidence base needs to be drawn on to provide a system-level overview of the relationship between alcohol advertising, advertising restrictions and consumption. Advertising aims to influence not just consumption, but also to influence awareness, attitudes and social norms; this is because advertising is a system-level intervention with multiple objectives. Given this, assessments of the effects of advertising restrictions which focus only on sales or consumption are insufficient and may be misleading. For this reason, previous systematic reviews, such as the 2014 Cochrane review on advertising restrictions (Siegfried et al) contribute important, but incomplete representations of 'the evidence' needed to inform the public health case for policy decisions on alcohol advertising. We conclude that an unintended consequence of narrow, linear framings of complex system-level issues is that they can produce misleading answers. Systems problems require systems perspectives.

Use of hyperbaric oxygen therapy and PEGylated carboxyhemoglobin bovine in a Jehovah's Witness with life-threatening anemia following postpartum hemorrhage

We present a case of a Jehovah's Witness patient who refused blood products, with the exception of albumin and clotting factors, and underwent cesarean section under spinal anesthesia complicated by postpartum hemorrhage. She was fluid resuscitated and treated with multiple uterotonics and internal iliac artery embolization. Because of agitation she required emergency tracheal intubation. Her hemoglobin concentration dropped from a preoperative value of 12mg/dL to 3mg/dL on postoperative day one. She was acidotic, requiring vasopressors for hemodynamic stability and remained ventilated and sedated. She was treated with daily erythropoietin, iron therapy and cyanocobalamin. Because of ongoing hemorrhage, continued acidemia and vasopressor requirements she was co-treated with PEGylated carboxyhemoglobin bovine and hyperbaric oxygen therapy to reverse her oxygen debt. On postoperative day eight her hemoglobin concentration was 7mg/dL, she was hemodynamically stable and vasopressors were discontinued. She was extubated and discharged from the intensive care unit on postoperative day eight. This report highlights the multiple modalities used in treating a severely anemic patient who refused blood, the use of an investigational new drug, the process of obtaining this drug via the United States Food and Drug Administration emergency expanded access regulation for single patient clinical treatment, and ethical dilemmas faced during treatment.

Electric field-assisted formation of organically modified hydroxyapatite (ormoHAP) spheres in carboxymethylated gelatin gels

A biomimetic strategy was developed in order to prepare organically modified hydroxyapatite (ormoHAP) with spherical shape. The technical approach is based on electric field-assisted migration of calcium ions and phosphate ions into a hydrogel composed of carboxymethylated gelatin. The electric field as well as the carboxymethylation using glucuronic acid (GlcA) significantly accelerates the mineralization process, which makes the process feasible for lab scale production of ormoHAP spheres and probably beyond. A further process was developed for gentle separation of the ormoHAP spheres from the gelatin gel without compromising the morphology of the mineral. The term ormoHAP was chosen since morphological analyses using electron microscopy (SEM, TEM) and element analysis (EDX, FT-IR, XRD) confirmed that carboxymethylated gelatin molecules use to act as organic templates for the formation of nanocrystalline HAP. The hydroxyapatite (HAP) crystals self-organize to form hollow spheres with diameters ranging from 100 to 500nm. The combination of the biocompatible chemical composition and the unique structure of the nanocomposites is considered to be a useful basis for future applications in functionalized degradable biomaterials.

STATEMENT OF SIGNIFICANCE

A novel bioinspired mineralization process was developed based on electric field-assisted migration of calcium and phosphate ions into biochemically carboxymethylated gelatin acting as organic template. Advantages over conventional hydroxyapatite include particle size distribution and homogeneity as well as achievable mechanical properties of relevant composites. Moreover, specifically developed calcium ion or phosphate ion release during degradation can be useful to adjust the fate of bone cells in order to manipulate remodeling processes. The hollow structure of the spheres can be useful for embedding drugs in the core, encapsulated by the highly mineralized outer shell. In this way, controlled drug release could be achieved, which enables advanced strategies for threating bone-related diseases, e.g. osteoporosis and multiple myeloma.

Limits on Active to Sterile Neutrino Oscillations from Disappearance Searches in the MINOS, Daya Bay, and Bugey-3 Experiments

Searches for a light sterile neutrino have been performed independently by the MINOS and the Daya Bay experiments using the muon (anti)neutrino and electron antineutrino disappearance channels, respectively. In this Letter, results from both experiments are combined with those from the Bugey-3 reactor neutrino experiment to constrain oscillations into light sterile neutrinos. The three experiments are sensitive to complementary regions of parameter space, enabling the combined analysis to probe regions allowed by the Liquid Scintillator Neutrino Detector (LSND) and MiniBooNE experiments in a minimally extended four-neutrino flavor framework. Stringent limits on sin^{2}2θ_{μe} are set over 6 orders of magnitude in the sterile mass-squared splitting Δm_{41}^{2}. The sterile-neutrino mixing phase space allowed by the LSND and MiniBooNE experiments is excluded for Δm_{41}^{2}<0.8  eV^{2} at 95%  CL_{s}.

Search for Sterile Neutrinos Mixing with Muon Neutrinos in MINOS

We report results of a search for oscillations involving a light sterile neutrino over distances of 1.04 and 735 km in a ν_{μ}-dominated beam with a peak energy of 3 GeV. The data, from an exposure of 10.56×10^{20} protons on target, are analyzed using a phenomenological model with one sterile neutrino. We constrain the mixing parameters θ_{24} and Δm_{41}^{2} and set limits on parameters of the four-dimensional Pontecorvo-Maki-Nakagawa-Sakata matrix, |U_{μ4}|^{2} and |U_{τ4}|^{2}, under the assumption that mixing between ν_{e} and ν_{s} is negligible (|U_{e4}|^{2}=0). No evidence for ν_{μ}→ν_{s} transitions is found and we set a world-leading limit on θ_{24} for values of Δm_{41}^{2}≲1  eV^{2}.

Methyl isobutyl ketone-induced hepatocellular carcinogenesis in B6C3F1 mice: A constitutive androstane receptor (CAR)-mediated mode of action

In a National Toxicology Program (NTP) chronic inhalation study with methyl isobutyl ketone (MIBK), increases in hepatocellular adenomas and hepatocellular adenomas and carcinomas (combined) were observed in male and female B6C3F₁ mice at 1800 ppm. A DNA reactive Mode-of-Action (MOA) for this liver tumor response is not supported by the evidence as MIBK and its major metabolites lack genotoxicity in both in vitro and in vivo studies. Constitutive androstane receptor (CAR) nuclear receptor-mediated activation has been hypothesized as the MOA for MIBK-induced mouse liver tumorigenesis. To further investigate the MOA for MIBK-induced murine liver tumors, male and female B6C3F1, C57BL/6, and CAR/PXR Knockout (KO) mice were exposed to either 0 or 1800 ppm MIBK for 6 h/day, 5 days/week for a total of 10 days. On day 1, mice were implanted with osmotic mini-pumps containing 5-Bromo-2-deoxyuridine (BrdU) 1 h following exposure and humanely euthanized 1-3 h following the final exposure. B6C3F₁ and C57BL/6 mice had statistically significant increases in liver weights compared to controls that corresponded with hepatocellular hypertrophy and increased mitotic figures. Hepatocellular proliferation data indicated induction of S-phase DNA synthesis in B6C3F₁ and C57BL/6 mice exposed to 1800 ppm MIBK compared to control, and no increase was observed in MIBK exposed CAR/PXR KO mice. Liver gene expression changes indicated a maximally-induced Cyp2b10 (CAR-associated) transcript and a slight increase in Cyp3a11(PXR-associated) transcript in B6C3F₁ and C57BL/6 mice exposed to 1800 ppm MIBK compared to controls, but not in Cyp1a1 (AhR-associated) or Cyp4a10 (PPAR-α-associated) transcripts. CAR/PXR KO mice exposed to 1800 ppm MIBK showed no evidence of activation of AhR, CAR, PXR or PPAR-α nuclear receptors via their associated transcripts. MIBK induced hepatic effects are consistent with a phenobarbital-like MOA where the initiating events are activation of the CAR and PXR nuclear receptors and resultant hepatocellular proliferation leading to rodent liver tumors.

Intra-operative assessment of excised breast tumour margins using ClearEdge imaging device

INTRODUCTION

Breast conserving surgery (BCS) aims to remove a breast cancer completely and obtain clear margins. Complete excision is essential to reduce the risk of local recurrence. The ClearEdge™ (CE) imaging device examines margins of excised breast tissue intra-operatively. The aim of this study was to investigate the potential of the device in detecting margin involvement in patients having BCS.

METHODS

In Phase-1 58 patients underwent BCS and had 334 margins assessed by the device. In Phase-2 the device was used in 63 patients having BCS and 335 margins were assessed. Patients with margins considered close or involved by the CE device were re-excised.

RESULTS

The margin assessment accuracies in Phase-1 and Phase-2 compared to permanent section pathology were very similar: sensitivity (84.3% and 87.3%), specificity (81.9% and 75.6%), positive predictive value (67.2% and 63.6%), and negative predictive value (92.2% and 92.4%). The false positive rate (18.1% and 24.4%) and false negative rate (15.7% and 12.7%) were low in both phases. In Phase-2 re-excision rate was 37%, but in the 54 where the CE device was used appropriately the re-excision rate was 17%. Had all surgeons interpreted all images appropriately and re-excised margins detected as abnormal by the device in Phase-2 then the re-excision rate would have been 7%.

CONCLUSION

This study shows that the CE device has potential to reduce re-excision after BCS and further randomized studies of its value are warranted.

Detecting the environmental impact of off-road vehicles on Rawdat Al Shams in central Saudi Arabia by remote sensing

Off-road vehicles can have a devastating impact on vegetation and soil. Here, we sought to quantify, through a combination of field vegetation, bulk soil, and image analyses, the impact of off-road vehicles on the vegetation and soils of Rawdat Al Shams, which is located in central Saudi Arabia. Soil compaction density was measured in the field, and 27 soil samples were collected for bulk density analysis in the lab to quantify the impacts of off-road vehicles. High spatial resolution images, such as those obtained by the satellites GeoEye-1 and IKONOS-2, were used for surveying the damage to vegetation cover and soil compaction caused by these vehicles. Vegetation cover was mapped using the Normalized Difference Vegetation Index (NDVI) technique based on high-resolution images taken at different times of the year. Vehicle trails were derived from satellite data via visual analysis. All damaged areas were determined from high-resolution image data. In this study, we conducted quantitative analyses of vegetation cover change, the impacts of vehicle trails (hereafter "trail impacts"), and a bulk soil analysis. Image data showed that both vegetation cover and trail impacts increased from 2008 to 2015, with the average percentage of trail impacts nearly equal to that of the percentage of vegetation cover during this period. Forty-six species of plants were found to be present in the study area, consisting of all types of life forms, yet trees were represented by a single species, Acacia gerrardii. Herbs composed the largest share of plant life, with 29 species, followed by perennial herbs (12 species), grasses (5 species), and shrubs (3 species). Analysis of soil bulk density for Rawdat Al Shams showed that off-road driving greatly impacts soil density. Twenty-two plant species were observed on the trails, the majority of which were ephemerals. Notoceras bicorne was the most common, with a frequency rate of 93.33 %, an abundance value of 78.47 %, and a density of 0.1 in transect 1, followed by Plantago ovata.

Clinical presentation, management, and outcomes in the Indian Heart Rhythm Society-Atrial Fibrillation (IHRS-AF) registry

Aim

A national atrial fibrillation (AF) registry was conducted under the aegis of the Indian Heart Rhythm Society (IHRS), to capture epidemiological data-type of AF, clinical presentation and comorbidities, current treatment practices, and 1-year follow-up outcomes.

Methods

A total of 1537 patients were enrolled from 24 sites in India in the IHRS-AF registry from July 2011 to August 2012. Their baseline characteristics and follow-up data were recorded in case report forms and subsequently analyzed.

Results

The average age of Indian AF patients was 54.7 years. There was a marginal female preponderance – 51.5% females and 48.5% males. At baseline, 20.4% had paroxysmal AF; 33% had persistent AF; 35.1% had permanent AF and 11% had first AF episode. At one-year follow-up, 45.6% patients had permanent AF.

Rheumatic valvular heart disease (RHD) was present in 47.6% of patients. Hypertension, heart failure, coronary artery disease, and diabetes were seen in 31.4%, 18.7%, 16.2%, and 16.1%, respectively.

Rate control was the strategy used in 75.2% patients, digoxin and beta-blockers being the most frequently prescribed rate-control drugs. Oral anticoagulation (OAC) drugs were used in 70% of patients. The annual mortality was 6.5%, hospitalization 8%, and incidence of stroke 1%.

Conclusions

In India, AF patients are younger and RHD is still the most frequent etiology. Almost two-third of the patients have persistent/permanent AF. At one-year follow-up, there is a significant mortality and morbidity in AF patients in India.

Effectiveness of cuticular transpiration barriers in a desert plant at controlling water loss at high temperatures

Maintaining the integrity of the cuticular transpiration barrier even at elevated temperatures is of vital importance especially for hot-desert plants. Currently, the temperature dependence of the leaf cuticular water permeability and its relationship with the chemistry of the cuticles are not known for a single desert plant. This study investigates whether (i) the cuticular permeability of a desert plant is lower than that of species from non-desert habitats, (ii) the temperature-dependent increase of permeability is less pronounced than in those species and (iii) whether the susceptibility of the cuticular permeability barrier to high temperatures is related to the amounts or properties of the cutin or the cuticular waxes. We test these questions with Rhazya stricta using the minimum leaf water vapour conductance (gmin) as a proxy for cuticular water permeability. gmin of R. stricta (5.41 × 10(-5) m s(-1) at 25 °C) is in the upper range of all existing data for woody species from various non-desert habitats. At the same time, in R. stricta, the effect of temperature (15-50 °C) on gmin (2.4-fold) is lower than in all other species (up to 12-fold). Rhazya stricta is also special since the temperature dependence of gmin does not become steeper above a certain transition temperature. For identifying the chemical and physical foundation of this phenomenon, the amounts and the compositions of cuticular waxes and cutin were determined. The leaf cuticular wax (251.4 μg cm(-2)) is mainly composed of pentacyclic triterpenoids (85.2% of total wax) while long-chain aliphatics contribute only 3.4%. In comparison with many other species, the triterpenoid-to-cutin ratio of R. stricta (0.63) is high. We propose that the triterpenoids deposited within the cutin matrix restrict the thermal expansion of the polymer and, thus, prevent thermal damage to the highly ordered aliphatic wax barrier even at high temperatures.

Using Speech Sounds to Enhance Occupational Performance in Young and Older Adults

Functional independence in daily life depends largely on performing daily occupations smoothly and efficiently. Thus, intervention is needed as the quality of daily occupational performance declines with age in older adults. Recent experimental studies indicate an interactive relationship between speech and upper extremity motor control. These studies led to the suggestion that speech sounds or vocalization might be used to enhance motor performance. The present study compared the effect of vocalization on a daily motor performance in young and older adults. It included 13 young (mean 22.5 years) and 13 older adults (mean 75.5 years) with no known neurological impairments who performed the task of reaching for a cup and placing it on a shelf during four randomly chosen conditions: no vocalization, synchronized self-vocalization, external (experimenter) vocalization, and imagery vocalization. Arm and jaw movements were recorded using a search coil system. Kinematic data were analyzed using a two-way mixed design analysis of variance (ANOVA) with post hoc contrast analysis. Older adults were consistently slower than young participants for all test conditions (p<.001). Movements in both young and older adults made with either self-vocalization or external vocalization were significantly faster and smoother than movements made without vocalization or using imagery vocalization (p<.001). Vocalization effects on movement performance were significantly more pronounced in older adults than in younger participants (p<.001). The results suggest that vocalization improves motor performance of the daily living task studied, and the study design has clinical potential that may be used for facilitating task-related motor performance in older adults.

PAN-EX: a pooled analysis of two trials of neoadjuvant chemotherapy followed by chemoradiotherapy in MRI-defined, locally advanced rectal cancer

BACKGROUND

EXPERT and EXPERT-C were phase II clinical trials of neoadjuvant chemotherapy (NACT) followed by chemoradiotherapy (CRT) in high-risk, locally advanced rectal cancer (LARC).

DESIGN

We pooled individual patient data from these trials. The primary objective was overall survival (OS) in the intention-to-treat (ITT) population. Prognostic factors were also analysed.

RESULTS

A total of 269 patients were included. Of these, 91.1% completed NACT, 88.1% completed CRT and 240 (89.2%) underwent curative surgery (R0/R1). After a median follow-up of 71.9 months, 5-year progression-free survival (PFS) and OS were 66.4% and 73.3%, respectively. In the group of R0/R1 resection patients, 5-year relapse-free survival (RFS) and OS were 71.6% and 77.2%, respectively, with local recurrence occurring in 5.5% and distant metastases in 20.6% of cases. Significant prognostic factors after multivariate analyses included age, tumour grade and MRI extramural venous invasion (mrEMVI) at baseline, MRI tumour regression grade (mrTRG) after CRT, ypT stage after surgery and adherence to study treatment. mrTRG after NACT was associated with PFS (P = 0.002) and OS (P = 0.018) and appeared to stratify patients based on the incremental benefit from sequential CRT. Among the outcome measures considered, in the subgroup of R0/R1 resection patients, ypT and ypStage had the highest predictive accuracy for RFS (concordance index: 0.6238 and 0.6252, respectively) and OS (concordance index: 0.6094 and 0.6132, respectively).

CONCLUSIONS

Administering NACT before CRT could be a potential strategy for high-risk LARC. In this setting, mrTRG after CRT is an independent prognostic factor, while mrTRG after NACT should be tested as a parameter for treatment selection in trials of NACT ± CRT. ypT stage may be a valuable surrogate end point for future phase II trials investigating intensified neoadjuvant treatments in similar patient populations.

Association between underestimation of tumour size by imaging and incomplete excision in breast-conserving surgery for breast cancer

Background

Completeness of excision is the most important factor influencing local recurrence after breast-conserving surgery (BCS). The aim of this case–control study was to determine factors influencing incomplete excision in patients undergoing BCS.

Methods

Women with invasive breast cancer treated by BCS between 1 June 2008 and 31 December 2009 were identified from a prospectively collected database in the Edinburgh Breast Unit. The maximum size of the tumour, measured microscopically, was compared with the size estimated before operation by mammography and ultrasound imaging. A multivariable analysis was performed to investigate factors associated with incomplete excision.

Results

The cohort comprised 311 women, of whom 193 (62·1 per cent) had a complete (CE group) and 118 (40·7 per cent) an incomplete (IE group) excision. Mammography underestimated tumour size in 75·0 per cent of the IE group compared with 40·7 per cent of the CE group (P &lt; 0·001). Ultrasound imaging underestimated tumour size in 82·5 per cent of the IE group compared with 56·5 per cent of the CE group (P &lt; 0·001). The risk of an incomplete excision was greater when mammography or ultrasonography underestimated pathological size: odds ratio (OR) 4·38 (95 per cent c.i. 2·59 to 7·41; P &lt; 0·001) for mammography, and OR 3·64 (2·03 to 6·54; P &lt; 0·001) for ultrasound imaging. For every 1-mm underestimation of size by mammography and ultrasonography, the relative odds of incomplete excision rose by 10 and 14 per cent respectively.

Conclusion

Underestimation of tumour size by current imaging techniques is a major factor associated with incomplete excision in women undergoing BCS.

Hepatoprotective effect of <i>Helicanthus elastica</i>

<p class="Abstract">Search for medicinal plants to treat liver disorders is an important research topic on herbs. Acute toxicity study is a prerequisite for safety and dose fixation for further pharmacological actions. In the present study, aqueous and 95% ethanolic extract of whole plant of <em>Helicanthus elastica</em> were subjected to acute oral toxicity. The aqueous and ethanolic extract revealed no observable changes in the rats up to the dose level of 2,000 mg /kg body weight. The extracts were then screened for paracetamol-induced hepatic injury at dose levels of 200 and 400 mg/kg body weight (1/10 and 1/5 LD₅₀based on toxicity study). The aqueous extract of whole plant of <em>H. elastica</em> was found to produce significant (p&lt;0.05) reversal of the paracetamol-induced changes in the measured biochemical and histopathological parameters at lower dose of 200 mg/kg which was found to be better than ethanol extract at the same dose level.</p><p class="Abstract"><strong>Video Clip:</strong></p><p class="Abstract"><a href="https://www.youtube.com/v/cO6HI1Kikxs">Acute toxicity study and others:</a> 5 min 38 sec</p><p> </p>

Molecular fingerprinting of Helicanthus elastica (Desr.) Danser growing on five different hosts by RAPD

Mistletoes are hemiparasitic plants growing on aerial parts of other host trees. Many of the mistletoes are reported to be medicinally important. The hemiparasitic nature of these plants makes their chemical composition dependent on the host on which it grows. They are shown to exhibit morphological dissimilarities also when growing on different hosts. Helicanthus elastica (Desr.) Danser (mango mistletoe) is one such less explored medicinal mistletoe found on almost every mango tree in India. Traditionally, the leaves of this plant are used for checking abortion and for removing stones in the kidney and urinary bladder while significant antioxidant and antimicrobial properties are also attributed to this species of mistletoe. The current study was undertaken to evaluate molecular differences in the genomic DNA of the plant while growing on five different host trees using four random markers employing random amplified polymorphic DNA (RAPD) followed by similarity matrix by Jaccard’s coefficient and distance matrix by hierarchal clustering analysis. Similarity and distance matrix data employing just 4 random markers, separately and the pooled data as well, revealed significant difference in the genomic DNA of H. elastica growing on five different hosts. Pooled data of similarity from all the 4 primers cumulatively showed similarity between 0.256 and 0.311. Distance matrix ranged from of 0.256 to 0.281 on pooling the data from all the four primers. The result employing a minimum number of primers could conclude that genomic DNA of H. elastica differs depending upon the host on which it grows, hence the host must be considered while studying or utilizing this mistletoe for medicinal purposes.

Abstract P1-10-27: Self-reported symptoms and interference issues in breast cancer patients

BACKGROUND: Breast cancer and its treatments produce multiple symptoms that significantly impact patient quality of life (QOL). Distress and impaired function are the most commonly referred symptoms [Cleeland CS, 2007]. Routine cancer care assessment of patient-reported outcomes (PROs), including symptoms, function, and QOL, has been shown to improve symptom management, identification of psychosocial problems, and patient-provider communication. The Symptom Inventory Tool (SIT) is an assessment tool that captures the patients' perceived symptom burden for real-time clinical intervention, taken at the point of no intervention (baseline) and every 21 days or greater. The SIT is comprised of 27 questions utilizing the M.D. Anderson Symptom Inventory tool (MDASI) [Cleeland CS, Cancer 2013], and validated assessment instrument with 8 questions added and a free text box by Cancer Treatment Centers of America (CTCA). CTCA is a national network of five hospitals that specialize in cancer treatment and integrative oncology.

PATIENTS & METHODS: Patients reported symptoms intensity using 19-item MD Anderson Symptom Inventory (MDASI) and 8 additional questions created by CTCA (constipation, swelling, mouth soreness, bleeding, sexual interest, family, hope & QOL). Symptoms were rated "at the worst" on an 11-point numeric scale ranging from 0 ('no present") to 10 ("as bad as you can imagine") in the previous 24 hours. SIT became an integral part of patient care at CTCA beginning in 2012.

RESULTS: From July 2012 to February 2015, a total of 3,740 outpatients with breast cancer were evaluated at CTCA.

A total of 13,852 assessments were analyzed. The assessments consisted of 3,513 completed at baseline, 2,237 completed at the 2nd follow up (FU), and 8,014 completed at 3rd FU or greater. Median age was 50 (range, 17-88), 60% of patients were ER+. Race: White (68%), Black (29%), and other (3%). Disease extension: locoregional (86%) and metastatic (13.6%). The average time since cancer was diagnosed were 35 months, and 50.7% of the patients received prior systemic therapy: chemotherapy (55%), hormone-therapy (41%), and immunotherapy (4%). Mean, standard deviation and inter quartile ranges at baseline assessment are depicted in.

Table 1.Patient Reported SymptomBaseline assessment statisticsPercentage of patients with severe symptoms at baseline and reporting a clinically significant change (2 points) at 2nd SIT assessment Mean +/- STDInterquartile range (IQR)Significant decreaseNo changeDistress3.0 +/- 3.0[0.5]695 (31.3%)594 (26.8%)414 (18.7%)Sadness2.5 +/- 2.9[0.4]622 (28%)718 (32.3%)358 (16.1%)Disturbed Sleep3.3 +/- 3.2[0.6]550 (24.8%)517 (23.3%)642 (28.9%)Mood2.6 +/- 2.7[0.4]549 (24.7%)678 (30.5%)447 (20.1%)Pain2.7 +/- 3.0[0.5]523 (23.9%)675 (30.8%)519 (23.7%)*IQR is a measure of variability, based on dividing a data set into quartiles. Quartiles divide a rank-ordered data set into four equal parts

CONCLUSIONS: The SIT was successful in identifying symptoms burden and interference with life issues in breast cancer patients. Distress, sadness, disturbed sleep, mood and pain were the most common reported symptoms. Early identification of patient burden symptoms allowed immediate intervention and improvement in approximately a quarter of patients.

Citation Format: Alvarez RH, Hartman S, Bosch B, Kendrick D, Cohen L, Fridman J, Ottersen D, Walcott K, Ware S, Castro I, Thomas J, Niu J, Ahn E, Denny D, Markman M. Self-reported symptoms and interference issues in breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-10-27.

Abstract P4-14-25: Single agent and combined targeting of PI3K, mTOR, HER2 and ER signaling in a panel of HER2+/ER+ versus HER2+/ER- breast cancer cell lines

Background: Altered PI3K/mTOR signaling, through activating mutations in PIK3CA and/or PTEN loss, has been implicated in resistance to both hormonal and HER2-directed therapeutics for breast cancer. Recent data from the BOLERO-1 phase III clinical trials demonstrate an improvement in progression free survival (PFS) of 7.2 months in patients with HER2+/estrogen receptor negative (HER2+/ER-) advanced breast cancer when treated with trastuzumab and paclitaxel plus the mTORC1 inhibitor, everolimus (Afinitor ®). However, improvement in PFS was not observed in patients with HER2+/ER+ positive disease. These data suggest that hormone receptor levels may influence the response of HER2-amplifed cells to both HER2 and PI3K/mTOR directed therapies in the absence of hormonally directed therapies. In this study, we investigated the role of ER in HER2+ breast cancer by screening a large panel of HER2+/ER- and HER2+/ER+ breast cancer cell lines for responses to single agent and combined treatment with PI3K, mTOR, HER2 and ER-directed therapeutics.

Materials and Methods: The anti-proliferative activity of BKM120 (pan-PI3K inhibitor), BYL719 (p110α-specific) and everolimus were assessed as single agents or in combination with trastuzumab and/or tamoxifen in a panel of six HER2+/ER+ versus six HER2+/ER- breast cancer cell lines in two-dimensional culture. Drug response IC50s were generated from actual cell counts as measured by Z2-particle counting. Biomarker analyses were conducted using baseline mRNA microarray (Agilent) and reverse phase protein array (RPPA) profiling of each of the cell lines to determine associations with response or resistance data.

Results: RPPA analysis confirmed the presence of higher levels of ER protein in the cell lines designated as ER+ and significantly higher levels of PTEN protein were detected in those cell lines. Interestingly, each of the PI3K/mTOR pathway inhibitors tended to have increased single agent activity in the ER+ relative to the ER- lines. Combined activity with trastuzumab and either BKM120 or BYL719 was observed in 6 of the 12 cell lines tested and occurred independent of ER status. Similarly, combined activity of everolimus and trastuzumab was also observed in both HER2+/ER+ and HER2+/ER- cell lines. In 3/6 HER2+/ER+ cell lines the addition of tamoxifen provided no benefit to the combination of trastuzumab and PI3K/mTOR pathway inhibitor, whereas in two cell lines mild antagonism was observed with the triple combination. Finally, one cell line did show significant potentiation from the addition of endocrine therapy on top of HER2/PI3K/mTOR targeting.

Discussion: These data confirm levels of estrogen receptor are likely playing a role in response to single agent PI3K/mTOR pathway inhibition and highlight the potential utility of combining endocrine therapy with HER2/PI3K/mTOR-directed therapeutics in a sub-group of HER2-amplified breast cancers. Further in depth biomarker analyses may reveal additional molecular alterations responsible for this differential sensitivity to the double and triple combinations and is underway.

Citation Format: O'Brien NA, Nichols CM, Thomas J, Conklin D, Kalous O, Linnartz R, Di Tomasso E, Hurvitz SA, Hirawat S, Slamon DJ. Single agent and combined targeting of PI3K, mTOR, HER2 and ER signaling in a panel of HER2+/ER+ versus HER2+/ER- breast cancer cell lines. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-14-25.

Abstract OT2-02-04: The LORIS trial: A multicentre, randomised phase III trial of standard surgery versus active monitoring in women with newly diagnosed low risk ductal carcinoma in situ

Background: The independent review of the UK National Health Service Breast Screening Programme reported (The Lancet, Volume 380, Issue 9855, Pages 1778 - 1786, 17 November 2012) on the benefits & harms of breast screening. It concluded that breast screening saves lives & acknowledged overtreatment. It encouraged randomized trials to elucidate the appropriate treatment of screen-detected ductal carcinoma in situ (DCIS) to gain a better understanding of its natural history. The LORIS trial addresses overtreatment of low & low/Intermediate grade screen detected (low risk) DCIS by randomizing patients to standard surgical treatment or active monitoring.

Trial Design: LORIS is a phase III, multicentre, 2 arm study, with a 2 year feasibility phase, in patients confirmed to have low risk DCIS by central pathology review. Patients are randomised to standard surgery or active monitoring with annual mammography. Patients will be followed up for a minimum of 10 years.

Key Eligibility Criteria:

1) Female 46 years or over.

2) Screen-detected or incidental microcalcification (with no mass lesion clinically or on imaging)

3) Low risk DCIS on large volume vacuum-assisted biopsy, confirmed by central pathology review

4) Patient fit to undergo surgery

Specific Aims: The LORIS Trial aims to establish whether patients with newly diagnosed low risk DCIS can safely avoid surgery without detriment to their wellbeing (psychological and physical) & whether those patients that do require surgery can be identified by pathological and radiological means.

Primary endpoint: Ipsilateral invasive breast cancer free survival rate at 5 years

Secondary endpoints: Overall survival; mastectomy rate; time to mastectomy; time to surgery; patient reported outcomes & health resource utilisation.

A digital image data repository and tissue bank provide a prospective resource for both translational & imaging studies.

Statistical Methods: A total of 932 patients will be randomized to a non-inferiority design to test the null hypothesis that active monitoring of women diagnosed with low risk DCIS is not non-inferior in terms of 5 year ipsilateral invasive breast cancer free survival (iiBCFS) rate compared to treatment with surgery. The iiBCFS rate will be compared across the two arms on a per protocol and intent-to-treat basis, using a 1-sided (α=0.05) log-rank test for non-inferiority. The iiBCFS rate is assumed to be 97.5% in the surgery arm giving 80% power to exclude a difference of more than 2.5% in the active monitoring arm at 5 years.

Present Accrual and Target Accrual: 21 UK centres are open & the feasibility phase of the trial is recruiting to target. The web based central pathology review process is functioning well with a one week maximum turn around. A further 40 centres will be opened on completion of the feasibility phase.

Contact: LORIS@trials.bham.ac.uk

This project was funded by the National Institute for Health Research [Health Technology Assessment Programme] (project number 11/36/16)

Department of Health Disclaimer: The views & opinions expressed therein are those of the authors & do not necessarily reflect those of the Health Technology Assessment Programme, NIHR, NHS or the Department of Health.

Citation Format: Francis A, Fallowfield L, Bartlett J, Thomas J, Wallis M, Hanby A, Pinder S, Evans A, Billingham L, Brookes C, Dodwell D, Fairbrother P, Gaunt C, Jenkins V, Matthews L, Pirrie S, Reed M, Roberts T, Wilcox M, Young J, Rea D. The LORIS trial: A multicentre, randomised phase III trial of standard surgery versus active monitoring in women with newly diagnosed low risk ductal carcinoma in situ. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT2-02-04.